POTD: Drowning

POTD: DROWNING

Causes:

·     misadventure

·     inadequate supervision of small children

·     neurological event e.g. epilepsy, stroke

·     cardiac event e,g, MI, HCM, dysrhythmia, long QT, short QT

·     impaired judgement e.g. intoxication

·     trauma

·     overdose

·     foul play

Pathophysiology:

·      Water enters the mouth

·      Voluntarily spat out or swallowed

·      One hold’s their breath until inspiratory drive is too high.

·      Water is aspirated in the lungs, and coughing occurs as a reflex

·      Continued aspiration leads to hypoxemia, loss of consciousness and apnea

·      Death usually occurs from seconds to a few minutes

Long term sequela are determined by:

Surfactant dysfunction and washout

Osmotic gradient damaging alveolar capillary membrane

Massive bloodstained pulmonary edema

Decrease in lung compliance, VQ mismatch atelectasis and bronchospasm

There is no significant difference in sea water vs fresh water, although fresh water has greater antibiotic prevalence.

HOSPITAL MANAGEMENT:

The Heimlich or other expiratory maneuvers are not believed to be of use in these patients.

Rewarm to 34C as quickly as possible; remove wet clothes, insulate with blankets, forced air warmer, warmed IVF, warmed lavage bladder, peritoneal, and chest lavage.

Early invasive ventilation as indicated by respiratory distress.

RESPIRATORY SUPPORT: ARDS lung protective ventilation, bronchodilation, consider proning and possibly ECMO.

KEY POINTS:

·      consider ECMO to aid in both respiratory and hypothermic management.

·      Resuscitation focus should be on ventilation due to loss of surfactant.

·      Hypothermia can be neuroprotective: hours of resuscitation may still lead to complete recovery.

·      Antibiotics should only be given if water was grossly contaminated, glucocorticoids are not recommended, and there is no strong data on the use of surfactant.

·      Symptomatic patients, those with shortness of breath, chest pain, cough, nausea or vomiting, should be monitored in the ED for a minimum for 6 hours and should be counseled on prevention and risk factors for drowning.

REFERENCES:

https://litfl.com/drowning/

https://www.aliem.com/resuscitation-of-a-drowning-victim/

EMS Protocol of the Week - Amputation (Adult and Pediatric)

Unfortunately, we’re not yet at the point of prehospital limb reimplantations, so until then, the protocol for amputations is pretty sparse – sterile wet-to-dry dressing, indirect cold storage, don’t let anything freeze, and transport.

That’s it!

Short email this week, don’t you think that deserves…a hand?

www.nycremsco.org for plenty of protocols, not enough jokes.

Dave

EMS Protocol of the Week - Anaphylaxis / Severe Allergic Reaction (Adult and Pediatric)

The prehospital approach to anaphylaxis in NYC is a good refresher of the graduated responsibilities and expectations of EMS providers across levels of training, especially as we are now seeing medication administration at each level:

-          One dose of IM epinephrine may be given at the CFR (firefighter) level

-          A second dose of IM epinephrine may be given at the BLS (EMT) level; EMTs may also administer nebulized ipratropium and albuterol, if needed

-          A third dose of IM epinephrine and additional albuterol nebs may be given at the ALS (paramedic) level; in addition, paramedics may administer steroids, diphenhydramine, and crystalloid fluids

-          OLMC may permit further doses of medications as needed

Remember that these protocols are formatted such that if, for example, a BLS unit is first on scene, EMTs will perform all the necessary actions under the CFR portion of the protocol prior to starting the EMT section. Similarly, paramedics will complete the CFR and EMT sections prior to starting the paramedic section.

Also bear in mind that the threshold between pediatric and adult dosing for IM epinephrine is either age > 9 years or weight > 30kg.

Reach out with questions! www.nycremsco.org and the protocol binder for more!

Dave